Technical and Clinical Outcomes of Laparoscopic-Laparotomic Hepatocellular Carcinoma Thermal Ablation with Microwave Technology: Case Series and Review of Literature

PURPOSE

To evaluate technical and clinical outcomes of intraoperative (laparoscopic/laparotomic) microwave ablation on HCC.

MATERIALS AND METHODS

This is a retrospective single-center study evaluating consecutive patients treated for very early/early-stage HCC with intraoperative microwave ablation from 1 July 2017 to 30 June 2023. In these patients, a percutaneous US-guided approach was excluded due to the nodule's suboptimal visibility or harmful location and liver resection for a deep position or adherences. Data about the clinical stage, surgical approach, liver pathology and nodules characteristics, technical success, complications, and follow-up were collected. Technical success was intended as the absence of locoregional persistence at follow-up CT/MRI controls.

RESULTS

A total of 36 cirrhotic patients (M:F = 30:6, median age 67 years) were enrolled; 18/36 (50%) had a single nodule, 13/36 (36%) had two, 4/36 had three (11%), and 1/36 had four (3%). Among the patients, 24 (67%) were treated with laparoscopy, and 12/36 (33%) with a laparotomic approach. Sixty HCCs of 16.5 mm (6-50 mm) were treated for 7 min (2-30 min) with 100 W of power. A total of 55 nodules (92%) were treated successfully and showed no residual enhancement at the first postoperative follow-up; the other 5/60 (8%) underwent chemo/radioembolization. There was one complication (3%): a biliary fistula treated with percutaneous drainage and glue embolization. The average hospital stay was 3.5 days (1-51 days), and patients were followed up on average for 238 days (13-1792 days). During follow-up, 5/36 patients (14%) underwent liver transplantation, 1/36 (2%) died during hospitalization and 1 after discharge.

CONCLUSIONS

Laparoscopic/laparotomic intraoperative HCC MW ablation is feasible in patients unsuitable for percutaneous approach or hepatic resection, with rare complications and with good technical and clinical outcomes.

Current Endovascular Management of Arterial Complications After Pediatric Liver Transplantation in a Tertiary Center

PURPOSE

Pediatric liver transplant surgery is burdened by arterial complications whose endovascular treatment is not standardized. We report the outcomes of a cohort of pediatric recipients with hepatic artery complications treated by endoluminal procedures.

MATERIALS AND METHODS

From December 2019 to December 2022, consecutive transplanted pediatric patients who underwent endovascular treatment of hepatic artery complications were reviewed. The analysis included: type of complication (occlusion, stenosis, pseudoaneurysm); onset (acute =  < 15 days, subacute = 15-90 days, late =  > 90 days); endovascular technique (angioplasty, stenting); complications and outcomes. Technical success was defined as the opacification of the hepatic artery at the final angiogram with < 50% residual stenosis and no pseudoaneurysms. Clinical success was defined by graft's and patient's survival.

RESULTS

Seventeen patients (8 males; median age 33 months, IQR 9-103) underwent 21 hepatic arteriography procedures for predominantly acute or subacute occlusions (n = 7) or stenosis (n = 11) with concurrent pseudoaneurysms (n = 4). Primary and secondary technical success was achieved in 13/18 and 3/3 procedures, respectively, with overall technical success of 76%. Angioplasty alone was successful in 5/21 procedures; stent-retriever thrombectomy was performed in one occlusion with thrombosis; stenting was required in 9/17 (53%) patients. Clinical success was obtained in 14/17 (82%) patients with hepatic artery patency after a median of 367 days (IQR 114.5-500). Clinical failure occurred in 3 permanent occlusions, with 2 deaths and 1 re-transplantation. Procedure-related complications included minor events in 3/17 (18%) patients and 1/17 (6%) death.

CONCLUSION

In liver transplanted children with hepatic artery complications, endovascular treatment may provide clinical success, with stenting often required in acute and subacute conditions.

LEVEL OF EVIDENCE

Level 4.

US-guided percutaneous thrombin injection to treat non-femoral artery pseudoaneurysms: preliminary experience and review of the literature

PURPOSE

To evaluate the clinical outcome of US-guided percutaneous thrombin injection in the treatment of non-femoral artery pseudoaneurysms (NFAP).

MATERIALS AND METHODS

Among all pseudoaneurysms treated in our institution, we retrospectively collected NFAP embolized with percutaneous thrombin injections from January 1, 2015, to December 31, 2021. The embolization was prompted for an ongoing antiaggregating/anticoagulation therapy, NFAP optimal US visibility, or high surgery-related risks. Causes, location, size and neck of NFAP, complications, number of repeated treatments, clinical success and patients clinical conditions at discharge were annotated. The endpoint for clinical success was the resolution of NFAP at postprocedural imaging, with no resort to surgery.

RESULTS

Eight consecutive patients (5 females, median age 73 years, range 46-84) underwent 16 procedures. Arterial damage was due to catheterization (3), CVC mispositioning (2), trauma, hemorrhagic diathesis and endoprosthesis endoleak. We treated humeral (2), subclavian (2), thyrocervical, anterior tibial, radial and pancreaticoduodenal arteries. Median pseudoaneurysm size was 530 mm² (range 32-2400 mm²), with a thin (7/8) or non-visible (1/8) neck. No complications occurred. Clinical success was obtained in 7/8 patients (88%), with a single treatment in 4, multiple in 3 cases (4 embolizations, 3 and 2, respectively). One patient underwent surgical suture after the second failed attempt of percutaneous embolization. Seven patients were discharged in good clinical conditions; one died during hospitalization, due to the worsening of the underlying cardiac disease.

CONCLUSIONS

Percutaneous US-guided thrombin injection to treat NFAP is feasible in selected cases, with rare complications. Clinical success is often reached, also by repeated injections.

CT renal arteriography as a novel imaging guidance for the percutaneous ablation of small renal tumors

PURPOSE

To report procedural data and outcomes of a novel image guidance technique, CT renal arteriography (CTRA), performed to target and ablate small intraparenchymal renal tumors.

MATERIALS AND METHODS

We retrospectively analyzed data of 2 patients undergoing CTRA-guided ablation for 3 renal intraparenchymal tumors, from February to March 2023. We previously evaluated tumor visibility with US/CEUS, and in all cases conspicuity was poor, whereas contrast-enhanced CT (CECT) clearly depicted all hypervascular nodules. Our primary endpoint was CTRA-guidance feasibility for renal ablation, defined as the precise probe deployment inside the target tumor. The secondary endpoint was CTRA-guided ablation technical success, intended as the inclusion of the whole tumor inside the necrotic volume, with 5 mm safety margins. RENAL scores, complications, procedural time, dose length product (DLP), serum creatinine variation and hospital stay length were also recorded.

RESULTS

A confident deployment of the probe tip inside the nodule was accomplished in all 3 cases, with a 100% of correct targeting. We observed immediate technical success after all 3 ablations. The 3 nodules had a RENAL score <7 points, and we encountered no complications due to line placement or ablation. The average time from preablative to postablative CTRA was 54 min (50-58min), with a DLP of 3632mGy*cm (2807-4458mGy*cm). Serum creatinine didn't show a significant variation after the procedures; both patients were hospitalized for 2 days.

CONCLUSION

Preliminary data showed that CTRA-guidance might provide unique advantages over conventional CECT-guidance to assist the ablation of small renal intraparenchymal tumor not visualized on US/CEUS.

Embolization in Pediatric Patients: A Comprehensive Review of Indications, Procedures, and Clinical Outcomes

Embolization in pediatric patients encompasses a large spectrum of indications, ranging from the elective treatment of congenital diseases of the cardiovascular system to the urgent management of acute hemorrhagic conditions. In particular, the endovascular treatment of central and peripheral vascular malformations and hypervascular tumors represents a wide chapter for both congenital and acquired situations. Thanks to the progressive availability of low-profile endovascular devices and new embolic materials, the mini-invasive approach has gradually overtaken surgery. In this review, the main embolization procedures will be illustrated and discussed, with a focus on clinical indications and expected outcomes. The most recent mini-invasive techniques will be described, with hints on the cutting-edge devices and embolic materials.

The Role of Imaging in Portal Vein Thrombosis: From the Diagnosis to the Interventional Radiological Management

PURPOSE

To illustrate diagnostic and interventional imaging for the characterization and treatment of portal vein thrombosis (PVT).

INTRODUCTION

The broad spectrum of congenital and acquired PVT manifestations is illustrated, with a focus on the pediatric population; diagnostic and interventional imaging techniques are described.

DESCRIPTION

PVT frequently presents as an incidental finding at imaging in the screening for liver diseases or for other unrelated reasons. PVT can be classified based on: extension (intrahepatic, extrahepatic, involving the spleno-mesenteric tract, etc.); degree (partial or complete); onset (acute or chronic); and with or without cavernomatous transformation. This comprehensive review relies on the experience gained from a large series of congenital and acquired PVT in a referral center for pediatric and adult liver transplantation. Diagnostic and interventional imaging techniques are described, including: color-Doppler and contrast-enhanced Ultrasound; CT and MR angiography; retrograde portography; percutaneous transhepatic, transplenic, and transmesenteric portography; transjugular intrahepatic portosystemic shunt creation. Pre- and post-operative imaging assessment of the surgical meso-rex bypass is discussed. The description is enriched with an original series of pictorial imaging findings.

CONCLUSION

PVT is a clinical condition associated with significant morbidity and mortality. Diagnostic and interventional imaging plays a crucial role in both conservative and operative management.

Embolisation of the parenchymal tract after percutaneous portal vein catheterization: a retrospective comparison of outcomes with different techniques in two centres

Background

Embolisation of the parenchymal tract is a key step after any other transhepatic or transplenic percutaneous portal vein catheterization since eventual venous bleeding is difficult to control and may require surgical management. Different techniques have been proposed to perform tract embolisation. The aim of this study is to compare the safety and efficacy of different techniques of haemostasis of the parenchymal tract.

Materials and methods

All the interventional procedures with percutaneous transhepatic or transplenic access to the portal vein (excluding ipsilateral portal vein embolisation) from January 2010 to July 2020, in two tertiary hospitals, were retrospectively analyzed. The following data were evaluated: access site, the technique of embolisation, technical success in terms of immediate thrombosis of the tract, safety and clinical efficacy in terms of the absence of hemorrhagic and thrombotic complications.

Results

One-hundred-sixty-one patients underwent 220 percutaneous transhepatic or transplenic portal vein catheterization procedures. The main indications were pancreatic islet transplantation, portal anastomotic stenosis after liver transplantation, and portal vein thrombosis recanalization. As embolic materials gelfoam was used in 105 cases, metallic micro-coils in 54 cases, and cyanoacrylic glue in 44 cases; in 17 cases the parenchymal tract was not embolized. Technical success was 98% without significant difference among groups (p-value = 0.22). Eighteen post-procedural abdominal bleedings occurred, all grade 3 and were managed conservatively; difference among groups was not significant (p-value = 0.25). We detected 12 intrahepatic portal branch thromboses not related to the embolisation technique; only one case of non-target embolisation was documented after liver tract embolisation with glue, without clinical consequences.

Conclusion

Embolisation of the parenchymal tract after percutaneous portal vein catheterization is technically safe and effective. No significant differences were found between coils, glue, and gelfoam in effectiveness and complications rate.

Level of evidence

Level 3, Cohort study.

Biliary complications in pediatric liver transplantation: findings of percutaneous transhepatic cholangiography in a large single-center cohort

BACKGROUND

Although biliary complications after orthotopic liver transplantation represent a common source of morbidity and mortality, decreasing graft survival, consensus is lacking on their management in the pediatric population.

OBJECTIVE

The aim of this study was to present the prevalence of such biliary complications and their interventional radiologic management with representative images.

MATERIALS AND METHODS

This retrospective study reports our experience with percutaneous transhepatic cholangiography in the management of biliary complications after orthotopic liver transplantation in pediatric patients. This study enrolled all pediatric patients (<18 years old) who underwent percutaneous transhepatic cholangiography for the management of biliary complications after orthotopic liver transplantation at a tertiary care center between January 2010 and December 2020. Diagnosis of biliary complications and indication to perform percutaneous transhepatic cholangiography were based on clinical, laboratory or radiologic data.

RESULTS

Among the 301 orthotopic liver transplantations, 78 (26%) developed biliary complications that were managed by interventional radiology: these included 52 (17.3%) biliary strictures, 19 (6.3%) bile leaks, 5 (1.7%) biliary stones, 1 (0.3%) iatrogenic biliary obstruction and 1 (0.3%) vanishing syndrome. The median time interval between orthotopic liver transplantation and the diagnosis of biliary complications was 6.0 years (interquartile range [IQR] 8.2 years). Percutaneous transhepatic cholangiography and biliary duct catheterization were successful in all cases, with low rates of complications that were variable among subgroups.

CONCLUSION

A wide spectrum of biliary complications can occur after pediatric orthotopic liver transplantation. In this large single-center experience, we highlight the value of percutaneous transhepatic cholangiography in their diagnosis and management. Percutaneous treatments in pediatric patients are safe and effective, providing resolution or serving as a bridge to surgery, including re-transplantation.

Accuracy of Inflow Inversion Recovery (IFIR) for Upper Abdominal Arteries Evaluation: Comparison with Contrast-Enhanced MR and CTA

Background: Inflow-sensitive inversion recovery (IFIR) is a recently introduced technique to perform unenhanced magnetic resonance angiography (MRA). The purpose of our study is to determine the accuracy of IFIR-MRA in the evaluation of upper abdominal arteries, compared to standard MRA and computed tomography angiography (CTA). Materials and Methods: Seventy patients undergoing upper abdomen Magnetic Resonance Imaging (MRI) in different clinical settings were enrolled. The MRI protocol included an IFIR-MRA sequence that was intra-individually compared by using a qualitative 4-point scale in the same patients who underwent concomitant or close MRA (n = 65) and/or CTA (n = 44). Celiac trunk (CA), common-proper-left-right hepatic artery (C-P-L-R-HA), left gastric artery (LGA), gastroduodenal artery (GDA), splenic artery (SA), renal arteries (RA) and superior mesenteric artery (SMA) were assessed. Results: IFIR-MRA images were better rated in comparison with MRA. Particularly, all arteries obtained a statistically significant higher qualitative rating value (all p < 0.05). IFIR-MRA and MRA exhibited acceptable intraclass correlation coefficients (ICC) values for CA, C-L-R-HA, and SMA (ICC 0.507, 0.591, 0.615, 0.570, 0.525). IFIR-MRA and CTA showed significant correlations in C-P-L-R-HA (τ = 0.362, 0.261, 0.308, 0.307, respectively; p < 0.05), and in RA (τ = 0.279, p < 0.05). Conclusions: Compared to MRA, IFIR-MRA demonstrated a higher image quality in the majority of upper abdomen arterial vessels assessment. LHA and RHA branches could be better visualized with IFIR sequences, when visualizable. Based on these findings, we suggest to routinely integrate IFIR sequences in upper abdomen MRI studies.